Back in the spring of 2010, White House officials liked to talk up the idea that their health-reform package was the Medicare of our time  a major piece of legislation that, while initially controversial, would become mainstream, as did the Great Society program. With todays House vote, the analogy needs a tweak: Think of the Medicare reform of the 1980s, not the 1960s, when Congress enacted and then, facing great criticism, reconsidered the catastrophic coverage.

Ten months since being signed into law, the Patient Protection Act remains controversial and unpopular. With todays vote, Republicans signal their ongoing opposition. Despite the presidents public statements suggesting that hes eager to move on, it seems that the big debate of the last year will be the big debate of this year  and the next.

Its true, though, that Democrats have passed their reforms. Todays vote will not change the legislation, of course  the Senate will not even consider the motion. But the actions of the House are just one in a series of assaults on the Democrats health care reforms.

Other challenges? Let me count them.

First, the courts: The individual mandate was struck down by a federal judge in Virginia. The case will eventually reach the Supreme Court. And a quick observation: Conservatives outnumber liberals on the nations highest bench.

Second, the states: Much of Obamacares implementation will fall to the states. Governors in Ohio, Florida, Georgia, Texas and a host of other states have already spoken critically of the legislation.

Third, the cost: The CBO suggests a modest cost savings over a decade  but such estimates are, historically, off by more than a bit. In time of record deficits, will either party really push for full implementation?

Fourth, the people: Americans continue to dislike this program with a majority favoring repeal (46 percent-40 percent in favor, according to the latest Gallup Poll).

But Republicans need to put away the champagne. Yes, they have done well to educate the public and shape the debate. But, unless they are careful, the coming years will see the implementation of many aspects of Obamacare. They are holding a symbolic vote and achieving a symbolic victory. Politics is about real victories, however.

Whats to be done?

Republicans have outlined a series of small but clever steps to slow down Obamacare over the next two years. They plan to hold hearings that will shed light on the thousands of pages of regulations being written behind closed doors by the administration; they plan to defund certain controversial aspects of the legislation, like the hiring of Internal Revenue Service agents; and they will continue to focus on eventually repealing it all.

Thats all well and good, but it means that much of the next two years will be lost.

Republicans, instead, should steal a page from the playbook of liberal Democrats, who have spent decades finding every opportunity to quietly advance their vision of a government-dominated health care sector. How? Tack on amendments to bills, even budget bills, attacking the worst aspects of the legislation. And that means working with moderate Democrats.

Such a strategy requires a key element: discipline. We cant attack all of Obamacare legislatively over the next two years. Instead, we should focus on three core areas:

Republicans should start by seeking to repeal Obamacares medical-device tax, which penalizes innovation in one of Americas most advanced industrial sectors  and does so at a time when that sector is vulnerable to Chinese competition. Several Democratic senators represent states rich in medical-device manufacturing and research jobs, so a bipartisan coalition here is realistic.

It would also be worthwhile to wipe out the Medicare Independent Payments Advisory Board, a panel with power  too much power  over what kind of care can and cant be reimbursed. Such power could change the way physicians practice, undermining the doctor-patient relationship, the cornerstone of modern medicine.

Finally, Obamacare includes new regulations that will add to the cost of insurance, reduce competition among insurers and increase health care bureaucracy. The act, for instance, forces every insurer to price its plans based on “community rating,” lumping everyone in a region into the same statistical pool to avoid “discrimination.”

But individual Democrats in the House and Senate might be friendlier to real competition  especially if its modeled after the exchange that every member of Congress enjoys access to.

Today, House Republicans are registering their disapproval of sweeping but unpopular legislation. With careful planning, they can help change the legislation itself over the next two years.